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What’s New in the Patient Safety World

November 2021

Yet Another Risk During MRI

 

 

We’ve done many columns on adverse events occurring in the MRI suite, some of them directly related to the MRI scanner and others indirectly related.

 

Recently, ISMP (Institute for Safe Medication Practices) reported on a new type of event during MRI scanning (ISMP 2021). They reported on two patients inadvertently given opioid overdoses via PCA infusion systems during MRI. The two cases were similar. In each, because the PCA pump was not MRI-compatible, extension tubing was used so that the PCA pump could be located outside the MRI scanner room. Staff added several feet of extension sets to the PCA tubing and “primed” the tubing using the pump, which contained morphine in one case and HYDROmorphone in the other. Each patient became somnolent and had oxygen desaturation before any PCA doses were given.

 

In one case, the nurse noted this before leaving the MRI room and suspected morphine overdose. The patient was given supplemental oxygen and multiple doses of naloxone. It was calculated that the patient had received a bolus of approximately 56 mg of morphine in the “priming” fluid.

 

In the second case, the MRI scanning was performed and the patient was reported to be sleeping throughout the scan. When the patient was brought back to the nursing unit, his respirations were minimal and shallow, and the patient was barely conscious. The patient required multiple doses of IV naloxone before returning to his baseline status. Again, it was concluded that the patient had received an inadvertent bolus of opioid due to the extension tubing setup and priming.

 

ISMP made several recommendations for safer practices. They noted that the hospital adopted a policy of removing patients from PCA pumps prior to undergoing MRI. However, they noted this requires alternative pain management and monitoring during the time it takes to perform the MRI (which could take anywhere from 15 to 90 minutes to complete) plus any transport time. Alternatively, ISMP notes there are MRI-compatible infusion pumps and shielded PCA pump systems that could be used.

 

ISMP also notes the hospital could elect to send the PCA pump with the patient and utilize extension sets for a basal rate, supplemented by a nurse injecting the patient with a prescribed bolus dose of pain medication, as necessary.

 

ISMP also points out that, while the risks with PCA pumps in this scenario are most risky, similar risks apply to when patients are receiving infusions of other medications (eg. insulin, anticoagulants, vasopressors). So, it is incumbent upon hospitals to ensure all staff are aware of these issues and that appropriate policies and procedures are in place to manage such patients when going for MRI.

 

 

Some of our prior columns on patient safety issues related to MRI:

 

 

Some of our prior columns on patient safety issues in the radiology suite:

·       October 2020              “New Warnings on Implants and MRI”

·       January 2021               “New MRI Risk: Face Masks”

·       May 25, 2021              “Yes, Radiologists Have Handoffs, Too”

 

 

 

References:

 

 

ISMP (Institute for Safe Medication Practices). How will PCA be administered to patients during an MRI? ISMP NurseAdviseERR 2021; 19(9): 2-3 September 2021

https://www.ismp.org/nursing/medication-safety-alert-september-2021

 

 

 

 

 

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